**7. Nonoperative treatment**

**Tubiana stage Degrees of extension deficit**

**Figure 2.** A patient with Dupuytren's PIP joint contracture with a flexion contracture of approximately 100°.

fascia. Digital cords frequently seen include central and spiral cords. Active and passive ROM testing during the intermediate disease will often reveal no limitations in patients with nodules,

Late disease is defined by contraction of cords and the classic "bent finger" appearance of Dupuytren's disease (**Figure 2**). Approximately 10% of Dupuytren's disease patients will present during the late stage of the disease complaining of a permanent bent finger [12]. Contracture of the MCP joint often occurs before the PCP joint. Contractures often lead to difficulties in activates of daily living and patients will report difficulties with chores, washing, putting a hand in a pocket, and handshakes. Inspection and palpation will reveal a contracted, fibrotic cord. Both active and passive finger extension of the effected finger will likely be impaired, the extent of which is determined by severity of disease. Pain with ROM is rarely reported and if present should prompt further evaluation. The table top test was described in 1982 by Hueston and is specific to a Dupuytren's diagnosis and has been used to stage disease progression [50]. The test involves placing the patient's hand on a tabletop with the palmar side down. The test is positive if the patient cannot flatten the hand against the table and is

but as cords form patients will begin to lose extension of the involved joint.

**5.3. Late phase**

66 Essentials of Hand Surgery

**Table 1.** Tubiana staging system based on a digit's total extension deficit [51, 52].

0 0, No disease N 0, Nodules present

indicative of the late phase of the disease.

I 1–45 II 46–90 III 91–135 IV >136

Despite the recent advances in understanding the pathophysiology of Dupuytren's disease the treatment options remain palliative and not curative. Non-operative treatment is recommended in patients with isolated disease without contractures and in patients with mild contractures without significant interference with activities of daily living. Observation is a reasonable non-operative option for many patients with early disease and minimal symptoms. Studies have estimated about 50.8% of patients with palpable nodules will progress to developing cords after 8 years from diagnosis, and of these only 17% will develop contractures meeting criteria for surgical intervention [53].

Surgery is the mainstay treatment for Dupuytren's contractures. However, non-operative interventions continue to be pursued as an alternative option to surgical intervention. Splinting and physical therapy have mostly been utilized as a post-operative intervention to prevent recurrence. Critics of splinting and physical therapy often express concern it may worsen the contracture if the contractile tissue is not first removed. In vitro studies have reported mechanical loads increase TGF-beta expression and thus enhance fibroblast contraction [54]. Few clinical studies have investigated orthosis or therapy as a non-operative intervention. Larocerie-Salgado et al. reported patients with mild PIP joint contractures had an average improvement of 14.6° (SD 5.1°) after wearing a volar hand-based extension splint at night and utilizing hand exercises and massage [55]. Another study comparing tension and compression orthosis worn for 20 hours per day reported significant improvement in the total active extension (TAE) of a digit in both groups compared to baseline TAE [56]. Overall there is minimal evidence regarding therapy and orthosis usage. There may be some benefit in preventing progression of a contracture in an isolated digit, but the possible benefit may be minimal and outweighed by interference of the splint and necessity for prolonged periods of daily use.

**7.2. Collagenase injections**

**8. Operative treatment**

of surgery as well as their functional goals.

**8.1. Soft tissues**

Collagenase injections were first approved for Dupuytren's contractures in 2010 by the United States Food and Drug Administration and are currently approved for the treatment of two Dupuytren's contracted joints in the same hand. Collagenase injections deliver an enzyme isolated from *Clostridium histolyticum* which is responsible for lysing the collagen in a contracted cord. After injection, the patient returns within 1–3 days for manipulation to straighten the digit. Hurst et al. reported good results following up to 3 injections with 64% of patients experiencing 0–5° of full flexion with no recurrence 90 days after treatment [63]. Common adverse events of collagenase included swelling, pain, bruising, tenderness, and pruritis. Complications related to tendon ruptures, skin atrophy, and complex regional pain syndrome (CRPS) are rare and have been reported in less 1% of patients [63, 64]. Recurrence rates following collagenase have been closely studied as well. Van beek et al. reported 2-year recurrence rates (>20-degree worsening) following one or more injections were 28.2 and 62.1% for MCP and PIP joints, respectively [65]. Peimer et al. reported 47% of successfully treated patients experience recurrence (>20° worsening) within 5-years following collagenase injections with PIP joints having a higher degree of recurrence at 66 versus 39% among MCP joints [64]. Collagenase injections provide a good treatment option for patients with a palpable cord causing a contracture.

Dupuytren's Disease

69

http://dx.doi.org/10.5772/intechopen.72759

Operative treatment of Dupuytren's disease is offered in patient with contractures of >30° at the MCP joint and any functionally bothersome PIP contracture. The goal of surgical treatment is to return full extension of the involved digits via various surgical techniques involving either incising or excising the diseased fascia. Dupuytren originally described an open palmar fasciotomy technique in 1831 and this was later popularized in 1964 by McCash et al. as the open-palm technique [6, 66]. The open-palm technique involved a transverse incision across the distal palmar crease followed by incising any Dupuytren cords. Multiple surgical methods have since been described and include open fasciotomy, segmental fasciectomy, limited fasciectomy, and dermofasciectomy. These techniques range from being minimally invasive to radical excision of the diseased tissue. It is important to consider the severity of contractures, extent of correction, and risk factors for recurrence in addition to protecting soft tissues when choosing the optimal surgical treatment. Surgery is ultimately an elective form of treatment and should prompt a conversation with patients regarding the risk and benefits

Proper handling of soft tissue is a key principle of surgical treatment of Dupuytren's contractures. Adequate exposure of the cord must be balanced with protecting the neurovascular bundles, providing adequate wound coverage, limiting the risk of skin necrosis, and avoiding secondary contractures from longitudinal scarring. Multiple skin incisions have been described to address these issues and include: transverse incisions in the palm and digit, a

Intralesional triamcinolone injections have also been proposed to deter the progression of Dupuytren's disease. Steroid treatment in Dupuytren's is linked to its effectiveness in reducing hypertrophic scars and keloids by degrading insoluble collagen. Ketchum and Donahue reported resolution of Dupuytren nodules in patients with mild disease (<15° joint contracture) after an average of three 60-120 mg triamcinolone injections spaced out over 6 weeks [57]. However, 50% experienced recurrence of disease and either underwent further injections or surgery. Other studies have utilized triamcinolone in patients with nodules but without flexion contractures and have demonstrated better outcomes with only a 6% recurrence at 5 years [58]. The high recurrence rates and complications including skin atrophy, transient erythema, depigmentation and tendon rupture have minimized the use of steroid injections in Dupuytren's disease [57, 58].

Non-operative treatment has recently expanded to include office-based procedures to provide patients with Dupuytren's contractures an alternative to surgery or treat patients unable to tolerate surgery. Percutaneous needle fasciotomy and collagenase injections are two clinic procedures that have recently gained popularity. Zhao et al. reported these two minimally invasive techniques comprised 14% of all procedures for Dupuytren's in 2007, but have more recently risen to 39% of all procedures [59].

#### **7.1. Percutaneous needle fasciotomy**

Percutaneous needle fasciotomy (PNF) utilizes a 25-gauge needle as a scalpel to incise the contracted cord at different levels while the digit is manually straightened. Prior to the procedure the dermis is injected with a local anesthetic to reduce pain and is followed by range of motion (ROM) exercises aimed at preventing recurrence of the cord. As described by Eaton, needle fasciotomy has four requirements including a contracture caused by a palpable cord, redundant skin, and a cooperative patient [60]. The benefits of the procedure include a low complication rate, early return of motion, and avoidance of surgery. Zhou et al. reported a complication rate of 5.2% after fasciotomy compared with 24.3% in a group undergoing limited fasciectomy [61]. However, PNF had a higher rate of recurrence at long-term follow-up. Van Rijssen et al. have reported recurrence rates following PNF as high as 63% at 3 years and 84.9% at 5-year follow-up [62]. Patients older than 75 years old with mild disease had the lowest rate of recurrence at 5 years. In general, PNF is a reasonable option for older patients who have developed a mild contracture due to a palpable cord and are well-informed of the recurrence risk but prefer a minimally invasive option.

#### **7.2. Collagenase injections**

mechanical loads increase TGF-beta expression and thus enhance fibroblast contraction [54]. Few clinical studies have investigated orthosis or therapy as a non-operative intervention. Larocerie-Salgado et al. reported patients with mild PIP joint contractures had an average improvement of 14.6° (SD 5.1°) after wearing a volar hand-based extension splint at night and utilizing hand exercises and massage [55]. Another study comparing tension and compression orthosis worn for 20 hours per day reported significant improvement in the total active extension (TAE) of a digit in both groups compared to baseline TAE [56]. Overall there is minimal evidence regarding therapy and orthosis usage. There may be some benefit in preventing progression of a contracture in an isolated digit, but the possible benefit may be minimal and outweighed by interference of the splint and necessity for prolonged periods of daily use.

Intralesional triamcinolone injections have also been proposed to deter the progression of Dupuytren's disease. Steroid treatment in Dupuytren's is linked to its effectiveness in reducing hypertrophic scars and keloids by degrading insoluble collagen. Ketchum and Donahue reported resolution of Dupuytren nodules in patients with mild disease (<15° joint contracture) after an average of three 60-120 mg triamcinolone injections spaced out over 6 weeks [57]. However, 50% experienced recurrence of disease and either underwent further injections or surgery. Other studies have utilized triamcinolone in patients with nodules but without flexion contractures and have demonstrated better outcomes with only a 6% recurrence at 5 years [58]. The high recurrence rates and complications including skin atrophy, transient erythema, depigmentation and tendon rupture have minimized the use of steroid injections in Dupuytren's disease [57, 58].

Non-operative treatment has recently expanded to include office-based procedures to provide patients with Dupuytren's contractures an alternative to surgery or treat patients unable to tolerate surgery. Percutaneous needle fasciotomy and collagenase injections are two clinic procedures that have recently gained popularity. Zhao et al. reported these two minimally invasive techniques comprised 14% of all procedures for Dupuytren's in 2007, but have more

Percutaneous needle fasciotomy (PNF) utilizes a 25-gauge needle as a scalpel to incise the contracted cord at different levels while the digit is manually straightened. Prior to the procedure the dermis is injected with a local anesthetic to reduce pain and is followed by range of motion (ROM) exercises aimed at preventing recurrence of the cord. As described by Eaton, needle fasciotomy has four requirements including a contracture caused by a palpable cord, redundant skin, and a cooperative patient [60]. The benefits of the procedure include a low complication rate, early return of motion, and avoidance of surgery. Zhou et al. reported a complication rate of 5.2% after fasciotomy compared with 24.3% in a group undergoing limited fasciectomy [61]. However, PNF had a higher rate of recurrence at long-term follow-up. Van Rijssen et al. have reported recurrence rates following PNF as high as 63% at 3 years and 84.9% at 5-year follow-up [62]. Patients older than 75 years old with mild disease had the lowest rate of recurrence at 5 years. In general, PNF is a reasonable option for older patients who have developed a mild contracture due to a palpable cord and are well-informed of the

recently risen to 39% of all procedures [59].

recurrence risk but prefer a minimally invasive option.

**7.1. Percutaneous needle fasciotomy**

68 Essentials of Hand Surgery

Collagenase injections were first approved for Dupuytren's contractures in 2010 by the United States Food and Drug Administration and are currently approved for the treatment of two Dupuytren's contracted joints in the same hand. Collagenase injections deliver an enzyme isolated from *Clostridium histolyticum* which is responsible for lysing the collagen in a contracted cord. After injection, the patient returns within 1–3 days for manipulation to straighten the digit. Hurst et al. reported good results following up to 3 injections with 64% of patients experiencing 0–5° of full flexion with no recurrence 90 days after treatment [63]. Common adverse events of collagenase included swelling, pain, bruising, tenderness, and pruritis. Complications related to tendon ruptures, skin atrophy, and complex regional pain syndrome (CRPS) are rare and have been reported in less 1% of patients [63, 64]. Recurrence rates following collagenase have been closely studied as well. Van beek et al. reported 2-year recurrence rates (>20-degree worsening) following one or more injections were 28.2 and 62.1% for MCP and PIP joints, respectively [65]. Peimer et al. reported 47% of successfully treated patients experience recurrence (>20° worsening) within 5-years following collagenase injections with PIP joints having a higher degree of recurrence at 66 versus 39% among MCP joints [64]. Collagenase injections provide a good treatment option for patients with a palpable cord causing a contracture.
